[Music] thank you for taking time from your busy day to watch this special presentation from the El Paso County Medical Society I'm Dr Joel Hendricks president of the El Paso County Medical Society and it is my hope that you will find our program of great interest educational and informative about the medical care provided by some of our best physicians in our country right here in the Borderland from all of us at the El Paso County Medical Society please enjoy tonight's [Music] program according to the cdc's national health and nutrition examination survey about 70% of adults in the United States are overweight 30 2% are obese and we'll talk about the definition of overweight and obese in a little bit women have unique issues with weight post- pregancy weight menopause weight and what roles do the hormones play our program addresses concerns about obesity and medical consequences we'll also talk about options that are available to help lose weight that is necessary to be healthy everything from traditional exercise and nutrition but also weight loss surgery if you have questions regarding this or any other topic that's covered here on the Al Paso physician please email the El Paso County Medical Society and that email address is EPM o aol.com again eped so aol.com and we will have them answered by one of the doctors that appear here on the program this evening's program is underwritten by hospitals of Providence and we also want to thank the AL Paso County Medical Society for bringing the show to you for over 26 years now I'm kathern Berg and you are tuned into the El Paso visition welcome back we are talking about women's health and weight loss surgery why is it that we're talking about weight loss surgery and specifically with women tonight I have found through our doctors that over 70% actually over 80% of those that are seeking weight loss surgery are women and of that 80% they are women of childbearing age so that's a big deal and we don't talk about it often enough in sometimes separating the Sexes out so we're going to talk a lot about that so with us this evening we have Dr Rebecca Montes who is an OBGYN and you're going to give us some very specifics on the gals um and again since we're talking about weight loss surgery mainly occurring with women who are still of childbearing age there's a lot that goes into that and hormones I think is a little bit yes pregnancy is a little bit and so we're going to really dive into that and again if there's questions about this always uh email the El Paso County Medical Society and we'll make sure to get those questions answered we also have Dr Benjamin clap who is a bariatric surgeon and who's been with us several times in the past um and I I have to I have to acknowledge the obvious because now I'm looking at you and I just have to crack up because I have all of these Graphics which you're going to see in a little while as we put things together and there is just a portion of your paper that I transferred over here and I tore it up in front of him he's like you're tearing up my paper I'm not tearing up your paper I already transferred but this is just to kind of keep me on track uh but Dr clap welcome back thanks for me um I want to kind of start off with the idea of being healthy and yes it's the idea of weight um that we're talking about tonight but in general weight carries so many different issues that affect people and when I say that I like to just kind of start off on everybody thinks about BMI and what the definition of BMI is so Dr clap if you can kind of describe what that is and you were talking earlier prior to the show also that with BMI there was in the past a certain BMI number that we thought okay well after this number Hits now it's time for surgery but that's also been adjusted over the years right so let's dive into that so the BMI stands for body mass index and what a body mass index is is it it tells us a little bit about the patients characteristics of their body so it's not a perfect uh metric by any means it was created in the 1880s by a French statistician it it we we can argue about its usefulness but the thing about it is that any doctor nurse practitioner PA can or medical assistant can can calculate it from your height and your weight and so what we do is we look at the height and we we look at the weight and we divide that by height squared so it would be you know me uh kilogram over meter squared and that's and and so it's not a perfect Uh u Way of measuring things but a bodybuilder may have a BMI that would be considered obese but it's just because of their muscle mass but for most people it works very well in populations okay so in the past uh we would use the body mass index of a cut off of 35 to have somebody qualify for surgery um and they would have to have two Associated comorbidities or things that are related to so talk about what a comorbidity that would something like diabetes or high blood pressure or obstructive sleep apne or urinary stress and condence arthritis anything that we can relate to obesity okay obesity helps contribute to that or if they had a body mass index are greater than 40 and they would qualify and most insurance companies do pay for Patric surgery now within those within those uh guidelines however for the first time in 31 years we the American Society of metabolic Andric surgeons and the International Federation for Society of obesity got together and we've we've Revisited this because for 31 years it was static and it stayed there and we realized that uh even as low as a BMI of 30 people will benefit from it because if you have pre-diabetes and high blood pressure and you're developing sleep apnea and you have a BMI of 32 why would we wait until you have a BMI 35 right in real terms that could be the difference of 15 PBS so we've dropped that to 30 so now it's 30 with u um two Associated comorbidities or greater than 35 okay insurance companies haven't quite caugh that's always the big question so I'm super happy that you brought that up so again when you're thinking about our audience and there's surgery there's surgery there's a point where people see bariatric surgery as elective surgery and there's a point where bariatric surgery really is a health issue surgery so I'd like to again for the perception of what people hear and see out there what do you guys hear and see about that and and maybe specifically on this and then what I want to do is come to women's issues on that as well because again it's the perception you all are doctors and you get how and you said it beautifully earlier why do we wait to a certain point why do we wait until they're sick to fix something right and so one of my pet peeves as a bariatric surgeon every bariatric surgeon has the same pet peeve is that people that think this is some sort of a cosmetic procedure or something exctly necessary for their health and there couldn't be anything further from the truth yes this is an elective operation there's never a time when this is an emergency but it's a life-saving operation it's not cosmetic and when we look at the root cause of all these medical problems it's obesity in fact we classify obesity as a disease we don't even think of it as a condition it's a disease and so does the centers of medicated Medicare they think of it as a disease and when we when we look at the combination of obesity and diabetes specifically I mean you're looking at taking a year off of of someone's life for every point that they're over a body Max index of 35 they they lose a year of life M so it's it's a public health nightmare it's a Public Health crisis in this country and across the world and we need to get rid of the idea that this is some sort of elective cosmetic procedure it's nothing could be further from the truth right and and there's all kinds and I know you know you're looking at any kind of a platform of watching TV it's like why do we in America and this was a point that you made too America used to be in the top five of people in the world that were obese and now we're dropping a little bit yeah I I know but I feel like I feel like shows like this and and people kind of get on the bandwagon of what's what's happing that's helping out a lot I would love to talk Dr Mones in this realm we've not had a an OBGYN and specifically speaking about women issues when it comes to bariatric surgery or weight and general I mean we all talk about it I'm I'm 56 years old menopause hit I'm a little Meier than I've ever been in my entire life um but what does that mean and what does that translate into and what is the obes role when we're looking at just seeing your patients every year for their year yearly exam where do that conversation come in well that conversation comes in quite often um women in general are always obsessed with their weight right constantly they're you know and a lot of women are are overweight or obese and one of the things that they're always you know they're they're they're obese not because they want to and they try by so many means to try to lose the weight and so they're always constantly looking at us for guidance or for help right so one of the things that I have to address a physician every time they come in for their annual exam their well women exam I have to check their BMI see what it is and then it kind of provides some sort of guidance and give them some sort of resources so that they could go ahead and utilize to be able to achieve the weight goal that they want and a different stages that we are as women you know in adolescence you know when you're in the reproductive age you know and then when you transition to menopause you go through a lot of different hormonal changes that are going to affect your weight and so you know we have to address those issues at those different you know times of their lives for that M so when you're talking about hormonal changes too and I'm I'm thinking of myself um and my daughter and just in general so before you hit puberty and then puberty hits and yes you start developing breasts you start getting the hips and things start you know filling out a little bit and then once you hit your 20s and you you really looking at pregnancy weight um I guess the fear is too that there is the thought of being too thin and the thought of being too thick and where in general is that line when you're looking at people in their 20s when I say people women in their 20s because there's so much media around it there's so much you know not just about being healthy but about just being skinny but that's something too we want to look at too it's not just about being skinny which is a whole another word that is loaded and I respect that completely because overweight is a word obese is a word morbidly obese is a word where on that BMI chart do you ask women to to fall well we always want them to be at a normal BMI which is a BMI anywhere from 18 to 24 okay something less than that's the question between 18 and 24 that's where you really want women to be at a normal BMI you know but women get so obsessed with their weight and then we also have to look at the opposite side of that you know with eating disorders as well because there's two obsessed with weight loss um but I usually address the issue when their BMI is greater than 25 overweight I'll introduce it I said you know what you're you're you're a little overweight let's you know let's discuss about what type of diet you're doing exercise things like that when their BMI is a little bit more than 30 then we'll start I'll refer to a dietitian it's important that they get a referral to the DI dietitian because a lot of people in general don't know how to eat they don't know we overeat too many portions on our meals I me go to Texas Road House give you big huge steaks that's about 12 dear Lord yeah you do you get three or four meals in one and and you really want to eat a very healthy diet I always recommend the Mediterranean diet I think that's the best type of diet that anybody should be eating it's a Well proportioned diet with a well proportion of your vegetables your fruits your your fats your proteins everything in there with that and I think that a dietitian will provide a good guideline to those patients as to how they could achieve their weight loss goals in that sense okay and then if their BMI is greater than 30 now or and they have comorbidities or they have a BMI greater than 40 then I'll offer them to refer to S bariatric surgeon like Dr okay so on that note for people who are listening to this right now to and I don't know if we talked about the BMI calculator but you can almost put that in any search engine you can literally put in BMI body mass index calculator put in your weight put in your height um and then take it from there right age is not a thing anymore was it at one point there's like an extra step I think with some other uh no age yeah not at all so from there and even as we're because everybody's got their phones with them right if they're watching this they can be like okay what's mine and they kind of pop it in there um so looking at that that normal that normal weight so here's a question now somebody realizes and or a doctor said you know what your BMI is 34 let's say so we're we're up there and they start referring to Dr Clapp or like you might want to consider what are some of the questions that a patient and let's say it's a brand new patient someone who's just exploring the idea of weight loss surgery what are some of the questions that you find they ask the most and some of the advice that you give them well so by the time a patient comes to me they they've really thought about this for a long time the average patient thinks about this for about two years before they approach a surgeon it's not something that's taken lightly by the patients it's not something taken lightly by doctors um so they thought about it they maybe watched uh social media Instagram or Tik Tok about it they may have family members have gone through it and so by that time their questions are more of the details of how can I get this done right um they they if they're coming to see me they've kind of made up their mind that they're probably going to do this or they want to do it I think that it's probably harder for her for Dr Monas to interact with these patients because they're on the fence they're looking for guidance should I try another diet should I try these new medications that I'm hearing about or should I just go straight to surgery and what's what's better and so her job might be even a little bit harder because by by the time they're coming to me they know they're coming to a specialist yeah like her conversation with the patient saying well look I notic that your weight's going up it can be patients can get offended oh yeah in my office it's a delicate issue right but in my office I have all this literature I have a big sign outside that says I do weight loss surgery and they know that I'm going to talk to them about it so it's not I still do general surgery I and I still get I think I've offended patients before talking to them about that but I feel it's my role as a surgeon and my role as a bariatric surgeon to make sure that I I'm mentioning this very important thing that could change our life and and and them to health so I I don't make any bones about it I'll just bring it up to anybody I'll talk to anybody about weight loss surgery but I think your job might be a little harder it a little bit hard are you fat I me no because a lot of times you know some women can get offended you know and I I kind of have to especially because it is very much body image body but you know for the most part most women tend to be very receptive because they are always concerned about their weight so I don't really have a hard time discussing it I think the fear that they have most is the surgery itself that that um you know the complications that might arise from having bariatric surgery stuff like that and and they're and so I try to give them some guidance on that because bariatric surgery is a huge commitment they have to be emotionally prepared and committed to doing that you know because if they have any doubt then they better not go and get it done they really have to to discuss but a lot of times I have patients that say oh no no I just want to do it on on my own and and they've they've gone years trying to do it on their own they they and they don't have any results right and Dr kap's point there is where diabetes tends to be a little bit more of an issue and sleep apnea which you know sleeping seems like oh it's a night's sleep but sleeping is huge if you're not getting it it really affects your body too completely um I have a question as a follow-up of just the mental state right when you're looking at being offended when you're looking at just in in general the psychological effects and this is good bad and indiffer right psychologically if someone's been overweight for a good portion of the white uh life it does affect them psychologically when you're saying about now the mental state of how and when one decides to have the surgery talk about maybe in your role dealing with women and the psychology around obesity and maybe talk about the psychology around someone who has seen Dr clap someone who has had the surgery someone who is feeling healthy now years later what have you seen in the the the weighing of that a lot of times when women are obese they're they're coming in very depressed they're they're depressed because they're they can't lose the weight they've tried and and these are women who have tried years and years and years going through different fat diets or whatever exercising programs and they still can't lose the weight and when I start bringing up the topic of of weight loss surgery you know and I start planting that little seed that you know what maybe this is a good thing for you you should might as want to consider it just go ahead and have a consultation with a bariatric surgeon get to know a little bit more about the procedure and see what the outcome and the only thing that I tell them that I have from patients who have had bariatric surgery in the past is that I have not had a single patient to date regret their surgery the only thing that they tell me is the only thing that I regret from bariatric surgery is not having it done sooner uhuh right so I want to bring up one thing and then I'm going to go into these great graphics of what types of weight loss surgery are available but Dr clap you had mentioned earlier about weight loss drugs Andor we talk specifically about OIC uh that was and is marketed and is primarily for diabetes but it's just the topic of the day so I feel like if we don't bring it up we're not addressing the elephant in the room so let's talk about in general the keto diet and all these gommies that you're seeing on the internet right and left and people are buying them up and then it's like well wait a minute that was a scam and how does one know what to try what not to try what's real um and then then we'll talk about insurance too in a minute but take you know where I'm going with that just just go to town on that entire topic right so I'm the medical director of the bariatric c west for for Providence and I've been doing this for 17 years and what I would encourage people to do is think of obesity and and overweight as a spectrum we don't we don't start uh just with a gastric bypass or gastric sleeve just like if you have diabetes you probably don't start on insulin right away we try tret we're going to try to modify your your lifestyle that doesn't work we're going to step up to Medical therapy that we're going to add more medical therapy so it's it's kind of like that so when I see patients I mean they may not all be ready for surgery and uh there's a a class of well there's a couple of anti-obesity medications um which the most new the newest and best ones are the semaglutide medications which are OIC and wovi and those work great but we don't necessarily even need to start there we can start with things like contrave or fenine and some of these old tried-and-true drugs that can lose about 5% of your body weight and what do those drugs physiologically do once they're in their system like what is it designed to do in Sy those are usually appetite suppressants now appetizing suppressant okay when we when we pull out the big gun which is going to be semaglutide which is OIC or wovi it's the same same medication it's a gp1 receptor Agonist so what we're doing is we're we're essentially bottling a gastric bypass and injecting it once a week into your body it's the same hormones that we change when we modify the body when we do surgery so what we're doing a surgery is we're changing the metabolic set point so a patient thinks that their their body thinks they're supposed to be 3 we're going to drop that down to 200 huh through an interaction in the brain and the gut and through gut hormones so those are our pharmacological targets so stite works great you can lose up to 16% of your total body weight that's pretty good that's really good I mean a bypass is about 26 so you're almost getting there in that range uh it has to be taken for long term and it's an injection once a week about two to 10% of people just flat out won't tolerate it oh wow they have pretty bad side effects and this is spreading like wild fire it's all over the country now and we're starting to see as we release this to millions of people that yeah it's probably going to be around 10% of people that really can't tolerate this medication and so so of that 10% of the people that aren't tolerating so what what is it that they do at that point I mean are they have to come off of it they just have to come off it right okay and is there another option for them at that point well at that point we have then um surgery but surgery can also be divided into sort of procedures so we have a couple of procedures that we can do that aren't surgery like an inter gastric balloon and I do that oh I can put a balloon that fills space inside somebody's stomach we do it endoscopically there's no incisions it's getting a camera in your mouth we place a balloon we take it out 6 months later so basically it's tricking the stomach and thinking it's full it's full and it does I mean it's exactly what it sounds like I mean there's no magic to it it it if you drink a a milkshake you're going to you know you're not going to lose weight it's going to go right past that balloon there's a procedure called the endoscopic sleeve gastroplasty which can also be done endoscopically and there's a there's a gastroenterologist that that Providence that do does that and then there's surgery and surgery's been around for a while describe that one though that you're talking about so that one is where an endoscope is placed in the patient's mouth they're under a general anesthesia so they're asleep completely and the stomach is sewn part of the stomach is sewn together pated together sewn together so that it creates a tubular stomach okay pretty good results at 2 years uh we don't have really long-term data on it we don't have big numbers on it but there was a recent trial in Lancet one of the big medical journals that so this is relatively new okay not not a bad uh uh procedure is not covered by insurance so patients have to pay cash for that and then of course we have surgery which is sort of our old standby and across the country a lot of my colleagues are saying they seeing a 15 to 20% decrease in volume and I'm not experiencing that but but these medications are going to to to do that I I think that there always will be a place for surgery I think that we're going to see a rebound after these medications I don't think it's going anywhere okay and then that that leads to the three surgeries four surgeries that I perform so I'm going to address this just because I was trying to do some research on this show before here because I want to go into the surgery with some of these medications um for example the second set that you're talking about it works while you're on the medication but it doesn't it's not like you can wean yourself off and and all the effects stay there no with the gp1 recept drag so I think that's important to bring up because it's it's not like if you're on it you're on it for life but if you're on it you kind of have to continue taking it the I mean if we take blood pressure medication and our blood pressure normalizes we don't quit taking the medication we keep taking it okay um what I'd like to do now because I have these great pictures in front of me right um then we've got so I'd like to talk about the s first and I'm going to I'm going to pronounce it wrong so the acronym for sad means what exactly U the S is a single anastomosis duodenal interposition okay that's why we call the S that's quite a mouthful and you you'll see a graphic of this on your screen that we're going to put up this is actually kind of a newer operation it's a modification of an old operation called the duodenal switch and uh the difference is is we create a single connection uh from the iliam to the duodenum which is the last portion of the small intestine to the first portion but and we divide the duodenum so we're bypassing most of the intestine and it also has a sleeve gastrectomy associated with it so you do both at the same time it's also can be used as a revision for sleeve gastrectomy if a patient gains weight again so it's kind of right now we have a coverage decision from Etna there federal Blue class I think pays for it a couple of insurances do but I think once that gets picked up more widespread then I think we'll see a lot more of this operation it's actually more effective than a gastric bypass it's a better treatment for diabetes than a gastric bypass okay and that's a great transition too and you know in hindsight I probably should asked this about this one latest uh but the gastric how often in again percentage wise because I know when we talk about the sleeve that's about 70% of the surgeries that you're doing now and then gastri bypasses about how many percentage MOS well it would be about the another 25% so this is prob is a lot smaller but it's I think it's a growing procedure I think we're going to see a lot of it so it's about 2 or 3% of what I do in my practice the the issue is insurance coverage okay um but it's a great operation I love it and I think it's going to be very important for revisions after sleep gastrectomies so here's going to be the question from the audience too that I that I'm imagining so when you're looking at insurance coverage it's almost like FDA approval right it's something that has to be done and proven for a certain amount of years you said this has been going on for about two-ish years if that's correct oh no it's been around okay it's been around okay so is there a reason uh and not that you can answer that or have a you know insurance so insurance covers the most popular at this point the gastric sleeve right um more than the others and why would that be is it that it's been around a lot longer is it no actually the SLE only been around for about 15 years but we have a lot of data on it's it's 70% of what we do in the United States probably do about 160,000 the year in the United States 180,000 so we kind of know it outcomes but we also know that a certain amount of patients are going to regain weight so we I think that's why the C becomes more popular now I see so that that's a good way of differentiating these surgeries as well so if you're looking at the sleeve there's there's a weight gain prob about 15 to 20% of people okay and that usually happens about how many years after the surgery it can be anywhere from 2 to 5 years later I mean you know 80% of people are going to maintain but but it does have a little more tendency than the gastric bypass in the sa okay so let's talk about the sleeve and how that is done because we're going to pull up that graphic as well and as we're describing to the audience what are you doing as a surgeon like what are you doing with the stomach and the sleeve Etc just explain the procedure if you could so the sleeve gastrectomy um is a resection of the stomach and it it it would look like the sleeve of a suit to whoever first described it there there's nothing in there there's no foreign body it it should just be called a vertical gastrectomy but okay the term sleeve kind of stuck but we remove about 80% of the volume of the stomach uh and it's gone forever you can't put it back in when remove it it's done laparoscopically it's usually one night in the hospital it can be done as an outpatient and selected patients uh very safe so when you mentioned safety earlier when you talk about this and and look at this I um I'm also assist assistant professor at Texas Tech and I do a lot of research and and and I just we have a paper under under review right now looking at safety of the sleeve gastric bypass versus common operations hip replacements hysterectomies things like that it it's it's as safe as a gallbladder surgery so wow you know they've gotten we've gotten these very safe as we've directed these operations into centers of excellence and into expert hands so so they they become incredibly safe actually so about about the safety of a gallbladder okay so people see the that that we not doing anything else to the intestines it's the the least invasive of all the operations we offer um you know one night in the hospital so so it's patient driven that that that the volume is patient driven really okay and in general and I know costs are different across the board uh depending on all kinds of things but in general how much is the surgery of the gastric sleeve and when you said insurance covers it do they cover it 100% do they cover it 80% or so it's it's a covered benefit so it would just be like anything if you go and get your knee replacement and they tell you well you have an 80 8020 deductible then you're going to pay 20% it's just like that just like anything else has it always been I feel like that's always been uh a question that's asked on the program okay very same thing with the gastric bypass in the city when it's covered there are cash right there are cash prices but you know I mean is a little cheaper than a bypass okay okay that makes sense so now let's talk but again this is we kind of giggle about it but it it's truly what people want to know right and I and I take pride in this program and that I try to ask the questions that people want to know um on that note so you talked about the the gastric bypass and I I understand from earlier when we had done shows in the past we talked about gastric bypass and then we also talked about the band and we're not doing the band at all anymore as I understand right the the there are people doing the band still but a very very small percentage of people we we just have better operations now okay and you know uh putting a form body and like that and you know it it worked for a lot of people it wasn't a horrible thing it was when we that's what we had but we have better things now and and so we we tend not to do that so people again who are watching that because we have a lot of people we've been doing the show for 26 years and so I say that often because there are a lot of people that come back and go oh I have the band and I did the band 10 years ago it's now maybe not working anymore is there an option to now go to a different type of surgery sure you can switch a band to any of these operations actually although I still manage band patients that I put bands in 15 years ago and I still manage them I I put in hundreds of bands and they I have plenty of patients are still very happy with their bands okay it's just that we we don't really put them in that much anymore okay but they can be converted to something else gotcha so let's talk about the the surgeon's role in the gastric bypass so you know again looking at the the video here or the the the graphic you can see what's being bypassed here but what is the idea here because there's a lot of the large intestine that's being bypassed small intestine small intestine but so what what we have with the gastric bypass it's been around since uh you know really about 55 years so we have a lot of data on this we have a lot of long-term data on it we kind of know it's ins and outs um it's still considered really the gold standard by most of us and we compare everything else to it um so what we do is we make a very small pouch at the upper portion of the stomach by dividing it uh leaving in a a part of the stomach about the size of a golf ball and then we bypass that portion of the stomach although it stays in the body it would still work if we hooked it up later it would still makes gastric acid still does things like that the the bypass limbs of intestines are usually around 3 feet and uh on both Limbs and then they meet up later and so food is sort of you know going past the stomach bypassing it and then all the pancreatic juices and bile and gastric juices kind of later in there makes all the noise your belly yeah okay but uh it's it's got a little better weight loss in the gastric sleeve uh better treatment of diabetes and again it's kind of stood the test of time it is more complex you know but this mortality of it is the same as a sleeve complication rates are slightly higher and and you say something like that it makes it sound bad when you're you're actually talking about a maybe a 2% to 4% total complication rate including things like nausea and stuff like that for serious complications like a a02 to0 4% risk so they're they're they're subclinical almost okay risk and that's a a nice transition too and and Dr Montes just because you're next okay um let's talk a little bit about postsurgery so once somebody has a weight loss surgery and I know there's different nutritional issues that may be coming up and what have you so just in your practice and feel free to kind of kind of jump in on this but what is it nutritionally that may or may not be different once somebody does have a weight loss surgery and how does one manage weight loss surgery going forward and and again basically through um nutrition I don't know how to say it how to describe it going forward well for sure as a gynecologist uhhuh women who undergo uh gastric bypass or gastric surgery um they usually don't have regular periods and so one of the things that we noticed immediately after having uh gastric bypass is that they're going to lose a lot of significant weight and their hormones are going to kind of revert back to normal and they're going to start having a lot of menstrual cycles okay so one thing that I do want to point out a lot is in abnormally more than once a month no they will start let me going back they start go back to normal so now they're going to start menstruating normally and one thing that I do want to mention AOG which is the American College of Oban they recommend if you don't want to get pregnant during this time because as gynecologists we don't recommend for them to get pregnant right away we usually want them to wait somewhere about I thought I think bariatric surgeons say maybe 12 to 18 months we prefer 18 to 24 months okay and the only and the only reason why we want them to do that is because they've invested so much in trying to get this weight loss surgery that we really want them to optimize their weight loss goal and also at this time we also want to make sure that we're looking out for any type of micronutrient deficiencies or any type of complications that may or may not arise after having weight loss surgery okay um so if they're we prefer them to be on some sort of birth control the only thing that we don't recommend is an oral birth control because sometimes they might not be able to absorb that medication orally due to some micronutrient deficiencies and so the birth control pill might not be as effective okay so we do provide other forms of contraceptives that are better effective than a pill okay and so absorption is kind of where I was going to originally as far as nutrition goes um when we're looking at and again we're looking at pre atal medications etc etc when someone does want to get pregnant so what I think stood out to me so well is when people are obese at a point where it does affect hormonally your system that you're not menstrating in a normal scale and that's something that I I didn't think about until you brought that up so on that note with BMI for example when is it that the overweight becomes such an issue that you're not menstruating normally usually and it's different for every every woman but usually if women can have a weight loss of about 10% that is enough to affect their menstrual cycles and they can actually start having normal menstrual cycles after that so it really is kind of tler to the to the individual okay um but when they have weight loss surgery we do see that their menstrual cycles can return back to normal as as soon as 3 months postop sometimes even 4 weeks after that okay and I'm understanding too if I could I have here a specific question uh that I have from previous shows can people get pregnant after having weight loss surgery absolutely and so what I'm understanding from you a little bit is that sometimes it is it is optimal to have weight loss surgery so that you can then carry the pregnancy and carry everything healthy while going I would much rather have somebody have bariatric surgery get to their optimal weight goal MH and then become pregnant as opposed to have having a patient who's obese and pregnant because obesity in itself carries a lot of complications and morbid talk specifically about that because I think that's something we don't hear often so uh what there's diabetes gestation of diabetes that I I understand too so if you are obese and pregnant and talk just in general about some of the complications that happen with those two combined right being obese um puts a patient at risk when they become pregnant of having a miscarriage they could have a still birth they could have congenital anomalies they um get themselves at risk of having gestational diabetes hypertension preclampsia help syndrome all of these are complications with obesity in addition to that they could have a large festal baby which can put them at risk for having a shoulder dtoa where the baby can get stuck at the time of vaginal delivery gosh yeah or it also increases the risk of having a c-section and they have a csection and they're obese sometimes they could have poor wound healing and they could have a wound infection or wound dehance um they could also have an increased risk of having a a thrombus they could have a DVT on the leg they could have a pulmonary embolism so all of these are complications that can arise from being pregnant and obese okay and once you take the obes and this is something I didn't talk about earlier so um I kind of hinted at it but there's there's overweight there's obese there's morbidly obese and when we're looking at those different stages and I know that Dodger clap you were talking about by the time somebody has an opportunity to see you this is something they've discussed this is something that has been you know that's been going on we spilled water I'm going to acknowledge the obvious here I don't have oh you know what I have a scarf check this out your scarf Tada um so by the time somebody gets to you and uh let's say that now morbid obesity is in the picture that's not just that there's obesity and now I'm morbidly obese when it's it's hard for me to say this because height and weight is a thing but how much does one have to way for them to be morbidly obese I know it's with the BMI body chart so really it's a it's a BMI of 35 but we we that's morly obese right and we actually prefer the classification of class one two or three obesity okay morbidly obese kind of has it's a terrible word can you tell I'm having a hard time like getting it out of my my I didn't want to like uh get all you know correct you know I didn't want to correct your hate speech but no I'm just see I know but literally I was looking at this and I thought okay well what are the different stages and that's how they have it like well calculators so we collect numbers on everything right you know the government does we do insurance companies do everybody is and when you look at for example a BMI over 35 for every BMI point over 35 you increase your risk of pre- clamsy about like 3% for everyone so it's just it's it's not a healthy thing to be plus the issues of fertility I mean uh and PCOS and things like that and when we get people to lose weight with something like a sleeve or a bypass or or by other means their fertility Ines by 80% MH you know their ability to carry a healthy pregnancy tell us why so again explain to the audience why the fertility why are you more fertile when you're not obese like just physiologically explain why that's the case well I'll take a shot at it but she knows a lot more about it but if that's not an inactive substance it's a very hormonally active substance and what what that does in your body is is a hormonally active substance I you know what that right there and when you have these sex hormones like estrogen and a female progesterone or testosterone and a man uh when a person has a lot of fat cells it will drive their their sexual hormones towards an androgenous State okay uh where it's a precursor to being male or female but it's neither and that's you're going to have trouble with your cycle and if you start having more of Androgen like hormones then you're not going to have normal Cycles anymore you become an ovulatory you're not going to be ovulating more because that's going to affect your your ability to have a normal menstrual cycle M and then that's where the infertility comes up sure and even with men I mean 80% of my patients are female but even with men they're going to have disorders of of of sperm motility they're going to have a lower sperm count they're going to have lower testosterone it affects everything it affects everything in your life okay and it does it does affect everything in your life um we're kind of at the point where we've got about you know 18 minutes before the show ends and the reason I'm saying this I've got a ton of questions here that I can talk about but I want to focus on some things that that you wanted to talk about before you got here because again to me this is new for us when we're talking about weight loss surgery of very much bringing in the female group in so in general as an OBGYN and talking about this what are some of the the questions that you get asked I know you bring you know when people come in to see you there are certain things that you ask them but in general what are the questions that you get asked from women um in general about their health with weight and and going down this road and I know there's there's so many right and again you were talking about too you don't want to offend anyone because once they get to Dr clap to your point they're already kind of in the mindset of I need to have some kind of surgery so we can talk about and let's talk about the age group I think when Dr clap was showing me about um people who are in this it's women from but 35 to 455 okay 25 to 45 so this is like again childbearing years I'm body image is so huge Etc yeah and and and like I said most of these women that are getting bariatric surgery are in a reproductive age and most of them want to have a pregnancy most of so that is primarily what they're asking you they're looking at trying to get pregnant and and this issue going forward okay that's very common for me I mean they come in and when can I have a baby I I heard this will help me have a baby and yeah so it's exactly and so I I guess my question to you would be how do you guide them when they like they've had bariatric surgery and they're they're planning a pregnancy what would you well again we recommend for them not to become pregnant you know within the first 18 to 24 months but that's recommendation that's not reality right the majority of the patients they start losing their weight they start feeling really good they start you know they're not using any protection right or they're taking a breath control pill and it might be not working as effective as it should be and what do you know they're pregnant so now they're coming to me and and because they haven't achieved their weight loss goal they might still be obese you know and Pregnant and So there's still going to have that risk of having gestational diabetes of having hypertension um preclampsia so we need to monitor for micronutrient deficiencies so I have to check to to see whether or not they're having adequate intakes of vitam micronutrient deficiencies so most of the time when you have weight loss surgery you're going to you may become deficient in the fat soluable vitamins like a d and k um a d e and k e and K Vitamin E and you can also have iron defic you could have folic deficiency you could have thyine deficiency so we need to make sure that we monitor to see whether or not deficient in any of those and we'll check them every trimester these deficiencies that in general kind of go hand in hand again I was talking about nutritionally what you're able to absorb in the body after some of these surgeries versus and sometimes if they're not absorbing them orally then we might have to you know replenish them IV like we might have to give them IV infusions okay you know once a week they become severe anemic okay the other and this is during pregnancy yes and we do encourage the patients to continue taking their vitamins that their bariatric surgeon has prescribed the only thing that I would make different is that I think that the vitamins that you usually prescribe have a high amount of vitamin E and those could be teratogenic on a fetus so it could cause birth control I I'm sorry birth defects okay so we usually recommend vitamin E levels that are less than 5,000 international units okay so to switch them to a prenal vitamin that will do that that would be the thing with it that that's exactly if they they got I think they should plant it and if they don't plan it we still need to get them on those vitamins uh right away the other thing that we have to worry about is is you know women can get morning sickness and and then that can affect it even more so it becomes a vicious cycle of not being able to get their vitamins because they're vomiting and then you know getting more vitamin deficiencies and so that's when something like IVs would be very helpful so we got to we got to watch them very closely now statistically they're going to carry their pregnancy a little easier uh things will be better but we've got to watch them real closely and the patient needs to take you know uh responsibility too with their OB and hopefully their surgeon they can they can come and say hi to me every once in a while but we we all got to work together to make sure that it's the safest thing possible but it is very safe after surgery yeah it is and I prefer them I would much rather them get pregnant immediately afterwards and than for them to be still obese right and then be pregnant with that exactly and another thing that I also want to say also depending on the type of procedure that they had um if it's a malabsorption procedure like the like the ruined wires like that they might not be able to tolerate the 50 g glucose tolerance test when we give it to them which we usually do at 24 and 28 let's bring that up so say that again so 50% glucose glucose tolerance test tell me what that is it's a it's this very high sugarly syrup basically that they that they drink within a 5 minute span and what we're doing is we're trying to see what if they're at risk for gational diabetes during the pregnancy okay and this is done before they get pregnant because we're looking at no this is done when they're pregnant so we usually do it if they have a family history or they have a history of gational diabetes in the prior we'll usually do the glucose load immediately when they come in at their first initial visit and then we'll repeat it again between 24 and 28 weeks because usually around that time they'll start to develop tational diabetes if they're prone to having it okay but if they have certain uh procedures that with the gastric bypass they might not be able to tolerate a glucose load and they could have at risk of having dump syndrome that's another one that I have from shows past dumping syndrome so I want to first talk about uh the explanation of What gestational diabetes is and why is that dangerous when you're pregnant is that something also that later on in life after pregnancy years later can come back um so gestational diabetes why is that so bad when somebody is pregnant and let's let's talk about that because we hear it often enough so it's like oh I had that oh my sister had that or my cousin had that but it's not really explained why it's such an issue well when you're pregnant the placenta tends to produce a lot of hormone um insulin like receptors hormones that can mimic the state of pregnancy and your pancreas usually produces enough insulin to be able to decrease that amount of of of glucose loat but on in women who can't can't perform that then they end up developing toal diabetes Now if you have tational diabetes when you're pregnant you have a 50% chance of continuing to have gational diabetes well not just just becoming a diabetic after you've um you've had your baby so usually if I have a patient who has gational diabetes we usually do a 75 gram glucose load 6 weeks postpartum to assess whether or not they still have diabetes or are they going to become diabetic okay and is there harm to the baby with having gestational diabetes if your diabetes is not controlled then the baby can become large for gestational age okay you can have a macrosomic baby um tell me what that is so it's a baby that's basically larger than what the gestational age is okay um and the baby is not diabetic but the baby's pancreas will be producing a lot of insulin to try to regulate the amount of glucose that's circulating in mom so there's a risk when the baby's born that the baby can become hypoglycemic and the sugars drop significantly and that can affect the baby okay so that is very very specific so just say just that's hard to say gestational diabetes um does affect again we hear about it often about later on in life then the pregnant person does have a higher risk of developing diabetes um but we don't hear often about what's happening with a child inside so and that's why I want that to really be something that that we talk about not only that but if you have a a diabetic patient who's pregnant and they're not controlling their sugars um there's also especially in the beginning of the pregnancy there's a huge risk of still birth and congenital anomaly so birth defects with the pregnancy as well and you know we want women when we're following them for their diabetes we want them to be honest with their sugars because a lot of times they they're not and it's going to show up it will show up eventually you know because we'll see it when we monitor the baby the baby will grow or or you know we'll just we'll be able to find out whether or not they're truly compliant with their with their you know diet and and their diabetes yes Dr clap well just interesting obesity is just such an interesting disease I mean people come to me all the time and and they ask about this and like I'm worried about the complications of surgery I'm worried about this and and and I'm a as a surgeon I'm a risk I'm a risk manager I manage risk because what we do is inherently risky and how do I make up sure a patient walks out of the hospital under their own power whatever surgery I do and when you hear these complications like that that convey all the way into The Offspring into the child right and that that was my point of and if we can reduce those risks we really need to consider that you know and and we need to flip that question on its head like oh how risky is a surgery like how risky is not getting the surgery how risky is trying to carry a child or a baby for 9 months you with gestational diabetes with preclampsia with help syndrome which are lifethreatening conditions so for people who don't know preclampsia explain what that is too and why that why Obed I learned about in medical school she's the expert okay so so preclampsia basically is hypertension while you're pregnant okay um we usually see it in the third trimester sometimes you know so later on in the later on so we always have to monitor for any any protein in their urine and they elevated blood pressures because um if you don't control the blood pressures then the patient can have a stroke or seizure and you know that's not enough oxygen getting into the baby so the baby can have placental insufficiency and the baby may not Thrive and could have a growth restriction as well okay and I have heard too that's you know not often but babies are sometimes taken early because of the dangers of going to full term or the pre preeclampsia is just an issue big enough for the babies to uh to be taken early it's a terrible way of saying it um but going into uh to labor earlier and and having that done um I I have so many questions here that talk about um El Paso specifically and the nation in general as far as diabetes so we're talking about gestational diabetes but in El Paso we have a higher rate of diabetes anyway is that also the case with pregnancy in women that have gestational diabetes is that higher in Al Paso than it is in other cities that you all are aware of I'm not really sure but I would assume that yes okay and then here's the other question I always ask when we we talk about diabetes and it's just interesting to get opinions of doctors as to why that is I mean why is it that is it our diet is it our exercise is it Hispanic population um you know we're 80 80% Hispanic population so what is the all the but but we're always like in the top I don't know 5% of the cities that have the highest rate of diabetes and I'm just kind of throwing that out there because often that is associated with weight this is a weight loss program we're talking about surgeries in general I'm throwing that out to who gen does play a massive role in that so I'm from El Paso but I did my surgical training in Arizona and for example the Puma Indians have a 100% penetrance of diabetes just the 100% the DI not even a thing I the diet is is no it's it's it's a really interesting population study wow but they're they're they're just their pancreases aren't used to a western diet it's just not going to happen so okay so genetics plays a huge role in it it does our diet plays a huge role in it and and our diet is really what's wrong with with everything it's you know when we look at obesity you know and we look at our role of diet in obesity and we look at the role of inflammation in obesity you know it's almost like we're dealing with an autoimmune disorder it's not it's an inflammatory disorder but it's it's almost like an autoimmune disorder the way it attacks everything it all I think begins and ends with our diet now there's a little more to to to obesity than our diet I mean there's a genetic predisposition there's you know family traits things like that but it's the plays a huge role and one of the things that we have to change after surgery and and one of the things that we make people go see a nutritionist board for months before we do surgery is so they can get used to those changes in their diet and so that that's a great Point too so I have here some questions about just prep for surgeries and again I know we talked about a good four surgeries three that are that are done most often and we're looking at surgery prep so they've come to see you there is a decision to have one of these surgeries done at that point what is the prep period and what do they do so you know talking about Nutrition a lack of and we haven't defined dumping yet on this show anyway um afterwards but the absorption absorption of nutrients in general is there well we have so this is an elective operation and we have time to to do these and we want to make sure that people maximize their chances of success what it really is is a tool and if we don't teach them how to use this tool and we don't teach them how to effectively use it and use it all the time and get in the habit of using it then long term they may not have the success they want with it so everyone that goes through the program has to see a psychologist to look for eating disorders to look at you know mood disorders things like that everyone has to see a nutritionist probably multiple times uh and then everybody has to go through sort of this educational process uh where we teach them about these operations so that they can make an informed decision and they know what they're they're getting and the insurance companies are the ones that kind of determine how long that pre-operative period is but it's going to range anywhere from 2 to 6 months okay um so even if somebody comes in and pays cash you're still going to have to do all that because these are very important steps in their Journey uh to getting weight loss surgery and maintaining their weight okay and when it gets to that point what what could be some things that people decide well I'm not going to go through with this surgery and that's a terrible question to ask on the show because this shows all about the weight loss surgery it's fine there's plenty of people that don't yeah okay that drop out I mean they may feel that it's just not right for them yet they may feel that they can do it on their own they may feel that just give a little bit more time maybe these new medications that they'll be able to do it and that's okay I always tell my patients unless they're 100% committed uh that uh that they shouldn't do it um no one can make the decision for them they have to make it for themselves it can't be the spouse it can't be the parents it can't be the it has to be them it has to come from within them and then when they're accepting of it then they'll they'll succeed with it but if they're kind of fighting it a little bit then they're going to be very unhappy and we try to prevent that at all cost I've had people leave the the preoperative area I've had people say well I'm going to go to the bathroom and they ran away and that's okay you know people are like what happened well you know we called them but we're we're not going to chase them down they were waiting for it and that's okay well it is a big decision and that's why again I I love having the show because I and bringing up the good the bad the every everything because sometimes you just have to really dive into it and when you know knowledge is power it's that's the way I always look at things knowledge is power of knowing how all this works out um when we are I'm going to I'm going to repeat this now because I think sometimes we're about 3 minutes before the show ends but if there are questions that you have I know it happens fast I'm telling you that on that note I'm going to say this really quick and if there's something else we want to add before the show wraps up let me know but if you got to the show a little bit late there are several places that you can watch the show again um the the just the simplest is pbsl pasel so pbsl pass.org you can go on there and L literally on that web page you will see the logo of the El Paso position you can find it there the El Paso County Medical Society website that's epcms decom and then everybody I feel like Knows YouTube and so several years ago PBS put this on YouTube and that works out beautifully so just go to youtube.com and just search the El Paso visition the nice thing about that is that you can go back to literally the weight loss surgery show that we did I don't even know how many years ago that was but they're all archived in there so you can find this show you can find other shows as well um so I want to throw that out there and you were just saying something before I said I wanted to get this out what was that that's that's a brain loss right there no that's okay but they could also go to my website and has that show on it also let's do that too let's go to your what's your website oh it's it's h just Google me I mean just go Dr Benjamin CL you gave you like you spelled it out and PBS look they're just going to Google and it will just show up yeah you know search engines that's the thing right but sometimes on that note in fact this is something great for OBS Dr Google is a thing right and so sometimes you will get bad information out there and I I address it every now and again but when people come see you as an OB and they say hey I read about what are some of the the things that are misinformed with a lot of people that you see and how do you direct them to a website and or a search engine that they can get real information and not just stuff that's thrown out there well I usually redirect them to to the acock website which is the American College of obj for my patients okay say that slowly ACOG the ACOG Cog ACOG okay American College of objn that's basically the college that we as OBGYNs follow all the recommendations that that they have for anything associated with Women's Health okay which makes a big difference yeah you know what that gave me a great idea so for us what I would like to say especially for my patients is that um go to the asmbs website which is the American societ you guys have to say it slower American Society of metabolic and bariatric surgeons and look up the nutritional guidelines because my patients that are out there and there's thousands of them you guys you got to take your vitamins you got to take your vitamins and it's just a good reminder of the official you know this is the the one that the they they bless this is these are the doses you need and these are the vitamins you need so that's always good to know because that's always the big question when you're in the grocery store right clap and Dr Montes thank you so much for being here again we've been talking about we've been talking about weight loss surgery in general but we've been trying to specify Women's Health and weight loss surgery and who to talk to and so again come back visit the show again and get to get all this information but we appreciate you watching thanks for being here um and tuning in I'm Katherine Berg and this has been the AL Paso physician thank [Music] [Music] [Music] you [Music] n